Validation of the Abdominal Pain Index using a revised scoring method

Validating a novel scoring system for the assessment and treatment of functional gastrointestinal disorders in children

BACKGROUND

Functional gastrointestinal disorders (FGIDs), defined as ‘Disorders of Gut-Brain Interaction’, are now considered a global health problem. There is a dearth of concepts and scales to assess the severity of the different symptoms encountered while dealing with the variety of FGIDs as described in the ROME IV classification. We introduced a novel scoring system with the incorporation of 16 different symptoms called Bacharyya’s Questionnaire Scale and started using it while dealing with children suffering from FGIDs.

AIM

To verify the usefulness and applicability of this recently developed scale, this study was undertaken with the objectives to establish the validity of this scoring system in assessing the severity of symptoms associated with a specific FGID in children and to determine the scoring system's applicability in assessing the treatment response.

METHODS

The study included children aged 5 to 18 years diagnosed with any FGID based on ROME IV criteria. They completed the newly developed scale and a Visual Analog Scale at initial diagnosis and after a 2-month treatment period. A control group without FGID participated for comparative baseline purposes. Treatment response was defined as a less than or equal to 50% reduction in the total score, which is statistically significant.

RESULTS

Results from a comprehensive cohort of 190 cases and 90 controls indicated a female preponderance (57.9%) and prevalent disorders such as functional constipation (28%) and functional abdominal pain, not otherwise specified (21%). The grade of FGID (mild, moderate, severe) experienced by the patients was also derived. Post-treatment, 96 children demonstrated symptom improvement. The Spearman rank correlation coefficient for pre (r = 0.72, 95%CI: 0.65-0.77, P value < 0.0001) and post (r = 0.49, 95%CI: 0.3-0.64, P value < 0.0001) treatment data showed positive results with significant P values.

CONCLUSION

The novel scoring system shows high comprehensibility and gives an objective view of the symptomatology of FGIDs. The use of this novel score in clinical settings will be helpful to typify the FGIDs and may significantly improve decision-making processes to initiate appropriate treatment.

Auricular Allodynia is Associated With Worse Outcomes in Children With Functional Abdominal Pain Disorders Using Neurostimulation

BACKGROUND AND AIMS

Percutaneous electrical nerve field stimulation (PENFS) is a minimally invasive, nonpharmacologic approach to treat children with functional abdominal pain disorders (FAPD). Allodynia refers to pain from a stimulus that does not usually provoke pain. We aimed to characterize auricular allodynia during PENFS and associate it with outcomes.

MATERIALS AND METHODS

We conducted a retrospective cohort study reviewing charts of patients who underwent PENFS for an FAPD. We included demographic data, medical history, and validated questionnaire responses. Allodynia was noted through physician notes of localized ear pain, soreness, or tenderness. Baseline clinical scores and PENFS outcomes were compared in patients with and without allodynia.

RESULTS

Of 219 patients with FAPD (mean age 16.2 ± 2.7 years), 79% were female, and 87% were Caucasian; 28% of patients experienced allodynia with no significant demographic differences. The most common gastrointestinal symptoms were abdominal pain (100%) and nausea (70%), and the most common FAPD diagnoses included irritable bowel syndrome (58%) and functional dyspepsia (54%). Of the 93 total visits with allodynia, 44% of the visits had patients report allodynia once and 34% twice. Common interventions included placing

CONCLUSION

Allodynia in patients with FAPD who underwent PENFS had worse clinical outcomes. Excitation thresholds of rapidly conducting Aβ fibers in the ear are lower than those of nociceptive slowly conducting Aδ and C fibers. Patients with allodynia may require adjustment of nerve fiber stimulation to improve outcomes.

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Key Words

• Functional abdominal pain
• irritable bowel syndrome
• nerve stimulation
• pediatrics
• side effect

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Affiliation(s)

Neha R Santucci Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
Umber Waheed Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
Jesse Li Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
Sherief Mansi Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
Kahleb Graham Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
Jennifer Hardy Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
Megan M Miller Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
Rashmi Sahay Division of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
Khalil El-Chammas Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA

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Youth With Functional Abdominal Pain Disorders Have More Sleep Disturbances. A School-Based Study

BACKGROUND

There is a bidirectional relationship between sleep and pain disturbances. Sleep disturbances increase the risk for chronic pain, while chronic pain can interfere with sleep. Hence, we assessed the subjective sleep characteristics of youth with functional abdominal pain disorders (FAPDs) compared to healthy youth and examined associations with gastrointestinal symptoms.

METHODS

We included youth ages 10-18 years without a sleep or organic GI disorder diagnosis from a large private school. Participants completed demographics, sleep history, and validated questionnaires: sleep quality (ASWS-SF), insomnia (PISI), daytime sleepiness (ESS), sleep disturbance (PROMIS SD), sleep-related impairment (PROMIS SRI), and Rome 4 diagnostic questionnaire. Cases (FAPDs) completed abdominal pain index (API), nausea severity (NSS), anxiety, depression (PROMIS), and functional disability (FDI). Parents filled sleep hygiene metrics (SHIP). Cases were matched 1:1 with controls based on age and gender.

RESULTS

Of 120 youth (60 cases and 60 controls), the mean age was 13.5 ± 1.9 years and 50% were females. Youth with FAPDs had higher insomnia, sleep disturbance, sleep-related impairment, daytime sleepiness, sleep hygiene, gasping, and nightmares than healthy youth (p < 0.05). Higher insomnia severity was associated with worse abdominal pain (r = 0.41, p < 0.01), higher daytime sleepiness with a family history of disorders of gut-brain interaction (DGBIs, OR = 14.7, p = 0.002), and higher sleep-related impairment (OR = 5.6, p = 0.02) and depression (OR = 6.1, p = 0.01) with black race.

CONCLUSION

Youth with FAPDs have worse sleep than healthy youth and multiple sleep parameters are associated with abdominal pain. Future studies could focus on determining mechanisms by which sleep disturbances affect abdominal pain and vice versa.

A systematic cognitive behavioral therapy approach for pediatric disorders of gut-brain interaction

OBJECTIVE

Cognitive Behavioral Therapy (CBT) for youth with Disorders of Gut-Brain Interaction (DGBIs) is effective; however, there are calls in the field to strengthen the evidence base and identify specific mechanisms of treatment that yield the most benefit for this patient population. A unique, systematic treatment approach of CBT with initial evidence for success for pediatric patients with DGBIs was evaluated to further demonstrate its clinical utility in this population.

METHODS

This was a retrospective study of 42 pediatric patients aged 11-17 years with DGBIs, who were diagnosed and referred for CBT by pediatric gastroenterology providers. Providers also completed a survey rating acceptability and effectiveness of CBT. The systematic CBT approach included 10 sessions delivered by a psychologist at an integrated Pediatric GI Clinic.

RESULTS

Review of 42 pediatric charts showed significant decreases in self-reported functional disability, abdominal pain, as well as depression and anxiety symptoms pre- to post-CBT completion. A moderation effect was observed where patients reporting higher levels of depressive symptoms and primary symptom of abdominal pain reported smaller reductions in functional impairment compared to those with lower levels of depression and primary symptom of nausea or vomiting. Pediatric Gastroenterology providers were satisfied with this psychological treatment approach.

CONCLUSIONS

This study provides evidence for acceptability and effectiveness of implementation of a systematic CBT approach for pediatric DGBIs in an integrated GI clinic, as well as areas worthy of future research, including identifying the most important mechanisms of treatment and factors that influence treatment response.

Pain Catastrophizing Moderates the Relationship Between Pain Sensitivity and Clinical Pain in Adolescents With Functional Abdominal Pain

Pain catastrophizing has been linked to amplified pain sensitivity assessed using quantitative sensory testing (QST) in adults; pediatric data are limited, particularly in youth with functional abdominal pain (FAP). With increasing use of QST to evaluate somatosensory function and predict pain outcomes, we examined the associations between QST and clinical pain in adolescents with FAP and tested the moderating effects of pain catastrophizing. Seventy-seven adolescents (mean age 16.6 years, 85.7% female, 72.7% White, 90.8% non-Hispanic) who fulfilled diagnostic criteria for FAP completed QST assessment (pressure pain threshold and tolerance, heat pain threshold, conditioned pain modulation) and measures of abdominal pain intensity, pain interference, and pain catastrophizing. Adjusting for age and sex, only higher heat pain threshold was associated with higher abdominal pain intensity (Beta per 1-standard deviation = .54, P = .026). Contrary to hypothesis, for youth with higher pain catastrophizing, higher pressure pain tolerance was associated with greater abdominal pain intensity, but associations were not significant for youth with lower catastrophizing (P = .049). Similarly, for those with higher pain catastrophizing (in contrast to lower pain catastrophizing), higher pressure pain thresholds and tolerance were associated with higher pain interference (P = .039, .004, respectively). Results highlight the need to investigate the influence of pain catastrophizing on QST. PERSPECTIVE: This study demonstrated unexpected findings of pain catastrophizing moderating the relationships between pressure pain threshold and tolerance, and clinical pain in adolescents with FAP. This raised questions regarding our understanding of psychological contributions to QST findings in pediatric populations with chronic pain.

A multicenter registry study on percutaneous electrical nerve field stimulation for pediatric disorders of gut-brain interaction

OBJECTIVES

Percutaneous electrical nerve field stimulation (PENFS) has demonstrated promise in single-center trials for pediatric abdominal pain-related disorders of gut-brain interaction (DGBI). Our aim was to explore efficacy of PENFS as standard therapy for DGBI in a registry involving multiple pediatric gastroenterology referral centers.

METHODS

This was a multicenter, prospective open-label registry of children (8-18 years) undergoing PENFS for DGBI at seven tertiary care gastroenterology clinics. DGBI subtypes were classified by Rome IV criteria. Parents and patients completed Abdominal Pain Index (API), Nausea Severity Scale (NSS), and Functional Disability Inventory (FDI) questionnaires before, during therapy and at follow-up visits up to 1 year later.

RESULTS

A total of 292 subjects were included. Majority (74%) were female with median (interquartile range [IQR]) age 16.3 (14.0, 17.7) years. Most (68%) met criteria for functional dyspepsia and 61% had failed ≥4 pharmacologic therapies. API, NSS, and FDI scores showed significant declines within 3 weeks of therapy, persisting long-term in a subset. Baseline (n = 288) median (IQR) child-reported API scores decreased from 2.68 (1.84, 3.58) to 1.99 (1.13, 3.27) at 3 weeks (p < 0.001) and 1.81 (0.85, 3.20) at 3 months (n = 75; p < 0.001). NSS scores similarly improved from baseline, persisting at three (n = 74; p < 0.001) and 6 months later (n = 55; p < 0.001). FDI scores displayed similar reductions at 3 months (n = 76; p = 0.01) but not beyond. Parent-reported scores were consistent with child reports.

CONCLUSIONS

This large, comprehensive, multicenter registry highlights efficacy of PENFS for gastrointestinal symptoms and functionality for pediatric DGBI.

Percutaneous Electrical Nerve Field Stimulation in Children and Adolescents With Functional Dyspepsia-Integrating a Behavioral Intervention

OBJECTIVES

Functional dyspepsia (FD) includes postprandial distress and epigastric pain syndrome. Percutaneous electrical nerve field stimulation (PENFS) in addition to behavioral interventions (BI) has shown benefits in children with functional abdominal pain but not specifically in FD. We aimed to assess the efficacy of PENFS for treating FD and compare the outcomes with those who received the combination of PENFS + BI.

MATERIALS AND METHODS

Charts of patients with FD who completed four weeks of PENFS were evaluated. A subset of patients received concurrent BI. Demographic data, medical history, and symptoms were documented. Outcomes at different time points included subjective symptom responses and validated questionnaires collected clinically (Abdominal Pain Index [API], Nausea Severity Scale [NSS], Functional Disability Inventory [FDI], Pittsburgh Sleep Quality Index [PSQI], Children's Somatic Symptoms Inventory [CSSI], Patient-Reported Outcomes Measurement Information Systems [PROMIS] Pediatric Anxiety and Depression scales).

RESULT

Of 84 patients, 61% received PENFS + BI, and 39% received PENFS alone. In the entire cohort, API (p < 0.0001), NSS (p = 0.001), FDI (p = 0.001), CSSI (p < 0.0001), PSQI (p = 0.01), PROMIS anxiety (p = 0.02), and depression (p = 0.01) scores improved from baseline to three weeks and at three months. Subjective responses showed nausea improvement (p = 0.01) and a trend for improvement in abdominal pain (p = 0.07) at week three. Abdominal pain subjectively improved at week three and three months (p = 0.003 and 0.02, respectively), nausea at week three and three months (p = 0.01 and 0.04, respectively), and a trend for improvement in sleep disturbances at week three and three months (p = 0.08 and p = 0.07, respectively) in the PENFS + BI group vs PENFS alone.

CONCLUSION

Abdominal pain, nausea, functioning, somatization, sleep disturbances, anxiety, and depression improved at three weeks and three months after PENFS in pediatric FD. Subjective pain and nausea improvement were greater in the PENFS + BI group than in the group with PENFS alone, suggesting an additive effect of psychologic therapy.

Percutaneous electrical nerve field stimulation compared to standard medical therapy in adolescents with functional abdominal pain disorders

Introduction

Standard medical therapy (SMT) in children with functional abdominal pain disorders (FAPD) includes cyproheptadine and amitriptyline. While percutaneous electrical nerve field stimulation (PENFS) has shown benefit, no study has compared outcomes of PENFS to SMT. We aimed to examine changes in abdominal pain, nausea and disability before and after treatment and compare outcomes between treatments.

Methods

The records of FAPD patients ages 11-21 years, treated with 4 weeks of PENFS, cyproheptadine or amitriptyline were reviewed. Outcomes were evaluated using validated questionnaires [Abdominal Pain Index (API), Nausea Severity Scale (NSS), and the Functional Disability Inventory (FDI)] at baseline and follow-up within 3 months (FU).

Result

Of 101 patients, 48% received PENFS, 31% cyproheptadine and 21% received amitriptyline. Median ages were 17 (15-19), 16 (15-18) and 15 (11-16) years respectively and the majority were females (75%, 90% and 52% respectively). In the PENFS group, API (p = 0.001), NSS (p = 0.059) and FDI (p = 0.048) were significantly lower at FU. API (p = 0.034) but not NSS and FDI (p > 0.05) decreased significantly at FU in the amitriptyline group. API, NSS and FDI did not change significantly with cyproheptadine at FU (p > 0.05). FU API scores were lower in PENFS vs. cyproheptadine (p = 0.04) but not vs. amitriptyline (p = 0.64). The FDI scores were significantly lower in the amitriptyline vs. cyproheptadine group (p = 0.03).

Conclusion

Therapy with PENFS showed improvements in abdominal pain, nausea and disability while amitriptyline showed improvements in abdominal pain within 3 months of treatment. PENFS was more effective than cyproheptadine in improving abdominal pain. Amitriptyline improved disability scores more than cyproheptadine and showed promise for treatment. PENFS may be a good non-pharmacologic alternative for FAPD.

The microbiome in adolescents with irritable bowel syndrome and changes with percutaneous electrical nerve field stimulation

BACKGROUND

Irritable bowel syndrome (IBS), a disorder of the gut-brain axis, is affected by the microbiome. Microbial studies in pediatric IBS, especially for centrally mediated treatments, are lacking. We compared the microbiome between pediatric IBS patients and healthy controls (HC), in relation to symptom severity, and with percutaneous electrical nerve field stimulation (PENFS), a non-invasive treatment targeting central pain pathways.

METHODS

We collected a stool sample, questionnaires and a 1-2 week stool and pain diary from 11 to 18 years patients with IBS. A patient subset completed 4 weeks of PENFS and repeated data collection immediately after and/or 3 months after treatment. Stool samples were collected from HC. Samples underwent metagenomic sequencing to evaluate diversity, composition, and abundance of species and MetaCyc pathways.

KEY RESULTS

We included 27 cases (15.4 ± 2.5 year) and 34 HC (14.2 ± 2.9 year). Twelve species including Firmicutes spp., and carbohydrate degradation/long-chain fatty acid (LCFA) synthesis pathways, were increased in IBS but not statistically significantly associated with symptom severity. Seventeen participants (female) who completed PENFS showed improvements in pain (p = 0.012), disability (p = 0.007), and catastrophizing (p = 0.003). Carbohydrate degradation and LCFA synthesis pathways decreased post-treatment and at follow-up (FDR p-value <0.1).

CONCLUSIONS AND INFERENCES

Firmicutes, including Clostridiaceae spp., and LCFA synthesis pathways were increased in IBS patients suggesting pain-potentiating effects. PENFS led to marked improvements in abdominal pain, functioning, and catastrophizing, while Clostridial species and LCFA microbial pathways decreased with treatment, suggesting these as potential targets for IBS centrally mediated treatments.

Percutaneous electrical nerve field stimulation improves comorbidities in children with cyclic vomiting syndrome

Introduction

Children with cyclic vomiting syndrome (CVS) frequently suffer from disabling abdominal pain and comorbidities that impair quality of life. A noninvasive, auricular percutaneous electrical nerve field stimulation (PENFS) device is shown to be effective for abdominal pain in children with disorders of gut-brain interaction. We aimed to determine the effects of PENFS on pain, common comorbidities, and quality of life in pediatric CVS.

Methods

Children aged 8-18 years with drug-refractory CVS were enrolled in a prospective, open-label study receiving 6 consecutive weeks of PENFS. Subjects completed the following surveys at baseline, during/after therapy (week 6), and at extended follow-up approximately 4-6 months later: Abdominal Pain Index (API), State-Trait Anxiety Inventory for Children (STAI-C), Pittsburgh Sleep Quality Index (PSQI), and Patient Reported Outcome Measurement Information System (PROMIS) Pediatric Profile-37.

Results

Thirty subjects were included. Median (interquartile range, IQR) age was 10.5 (8.5-15.5) years; 60% were female. Median API scores decreased from baseline to week 6 (p = 0.003) and to extended follow-up (p < 0.0001). State anxiety scores decreased from baseline to week 6 (p < 0.0001) and to extended follow-up (p < 0.0001). There were short-term improvements in sleep at 6 weeks (p = 0.031) but not at extended follow-up (p = 0.22). Quality of life measures of physical function, anxiety, fatigue, and pain interference improved short-term, while there were long-term benefits for anxiety. No serious side effects were reported.

Conclusions

This is the first study to demonstrate the efficacy of auricular neurostimulation using PENFS for pain and several disabling comorbidities in pediatric CVS. PENFS improves anxiety, sleep, and several aspects of quality of life with long-term benefits for anxiety.Clinical trial registration: ClinicalTrials.gov, identifier NCT03434652.

Telehealth for Pediatric Disorders of Gut-Brain Interaction During the COVID-19 Pandemic

A retrospective chart review was completed to examine psychological treatment duration and response among pediatric patients with a disorder of gut-brain interaction including functional abdominal pain and irritable bowel syndrome. Cognitive behavioral therapy (CBT) was delivered via telehealth with a licensed psychologist or supervised psychology trainee embedded in a pediatric gastroenterology clinic. Participants were 22 youth (mean age = 14.36 years) who received CBT via telehealth between February and September of 2021, after completing an initial evaluation between February and July of 2021. Patients completed reliable and valid self-report measures of functional disability and pain during treatment. A unique CBT model was employed with an initial focus on psychoeducation and function regardless of level of severity of functional impairment. Consistent with study hypotheses, nonparametric statistical analyses demonstrated statistically significant reductions in functional disability and pain following implementation of the CBT model via telehealth. Contrary to predictions, there was no relation found between severity of functional impairment and duration of treatment.

Randomised controlled trial of melatonin for paediatric functional abdominal pain disorders

AIM

Melatonin seems to have a positive impact on the brain-gut axis and many direct and indirect effects on the gastrointestinal tract. This trial aimed at assessing the efficacy of melatonin combined with Lactobacillus Rhamnosus GG given in the treatment of paediatric patients with functional abdominal pain disorders.

METHODS

Forty-two patients aged 4-18 years old who fulfilled the Rome IV Diagnostic Criteria for functional abdominal pain disorders were enrolled. Melatonin 3 or 5 mg in combination with Lactobacillus Rhamnosus GG (group 1, n = 22) or a placebo in combination with Lactobacillus Rhamnosus GG (control group, n = 20) were taken in the evening for a period of 4 weeks. The study duration was 12 weeks. The primary study endpoint was represented by clinical improvement at week 12 - defined as at least a 50% reduction in mean abdominal pain index (API) from baseline to week 12.

RESULTS

The mean API was reduced by more than 50% between T0 and T2 in the group of children treated with melatonin. However, the difference in the distributions of the variations of the scores between the two groups was not significant between T0 and T2 (P = 0.082), while it was significant between T0 and T1 (P = 0.001). Similar results were obtained by analysing the API variables 'weekly frequency of pain' (item 1) and 'perceived intensity of pain' (item 4) individually.

CONCLUSIONS

This is the first study to investigate the role of the combination of melatonin and Lactobacillus Rhamnosus GG in the treatment of children with functional abdominal pain disorders. Melatonin combined with Lactobacillus Rhamnosus GG can be considered a therapeutic option for these conditions in children.

Perspective: Assessing Tolerance to Nondigestible Carbohydrate Consumption

Human intestinal enzymes do not hydrolyze nondigestible carbohydrates (NDCs), and thus, they are not digested and absorbed in the small intestine. Instead, NDCs are partially to completely fermented by the intestinal microbiota. Select NDCs are associated with health benefits such as laxation and lowering of blood cholesterol and glucose. NDCs provide functional attributes to processed foods, including sugar or fat replacers, thickening agents, and bulking agents. Additionally, NDCs are incorporated into processed foods to increase their fiber content. Although consumption of NDCs can benefit health and contribute functional characteristics to foods, they can cause gastrointestinal symptoms, such as flatulence and bloating. As gastrointestinal symptoms negatively affect consumer well-being and their acceptance of foods containing NDC ingredients, it is crucial to consider tolerance when designing food products and testing their physiological health benefits in clinical trials. This perspective provides recommendations for the approach to assess gastrointestinal tolerance to NDCs, with a focus on study design, population criteria, intervention, comparator, and outcome. Special issues related to studies in children and implications for stakeholders are also discussed. It is recommended that the evaluation of gastrointestinal tolerance to NDCs be conducted in randomized, blinded, controlled crossover studies using standard gastrointestinal questionnaires, with attention to study participant background diets, health status, lifestyle, and medications.

Relationships Between Abdominal Pain, Mental Health, and Functional Disability in Youth With Inflammatory Bowel Diseases: Pain Catastrophizing as a Longitudinal Mediator

OBJECTIVES

Abdominal pain can be a debilitating symptom for youth with inflammatory bowel diseases (IBDs). Across various pediatric conditions, pain predicts adverse physical and mental health outcomes. Understanding mechanisms by which pain impacts outcomes is of critical importance to enhance the well-being of those with IBDs. Pain catastrophizing mediates the aforementioned relationships in other pediatric populations, but little research has examined its role in pediatric IBDs. Attention to the role of pain catastrophizing as a potential mediator in pediatric IBD is the important given unique elements of the pain experience for this population. This study aimed to examine pain catastrophizing as a potential mediator of the relationship between abdominal pain and adverse outcomes in youth with IBDs.

METHODS

Seventy six youth (ages 11 to 18; M [SD] age=14.71 [1.80]) with IBD completed the Abdominal Pain Index (T1), Pain Catastrophizing Scale (T2, week 12), Revised Children's Anxiety and Depression Scale (T3, week 20), and Functional Disability Inventory (T3, week 20).

RESULTS

Catastrophizing mediated the relationship between abdominal pain and both anxiety symptoms ( b =1.61, Bias-Corrected Accelerated [BCa] CI, 0.25, 4.62) and functional disability ( b =0.77, BCa CI, 0.15, 2.38). A direct effect of abdominal pain on low mood was also noted ( b =1.17, BCa CI, 0.03, 2.50). Post hoc analyses examining mediation via catastrophizing subscales indicated that while magnification and rumination functioned as mediators, helplessness did not.

DISCUSSION

Findings are consistent with fear avoidance models and suggest that interventions directed at pain catastrophizing may be worthwhile in pediatric IBD populations, given catastrophizing-mediated relationships between pain and mental and physical health outcomes.

Appraisals of Pain in Pediatric Inflammatory Bowel Disease: A Qualitative Study With Youth, Parents, and Providers

Background

Pain is a predominant symptom of inflammatory bowel disease (IBD), and is influenced by cognitive, emotional, and behavioral factors. The cognitive-affective model of symptom appraisal (CAMSA) has been used to understand how youth view symptoms in chronic conditions. We sought to (1) determine how youth with IBD and their parents appraise pain, and how their perspectives fit within CAMSA, and (2) explore health care providers' understanding and communication about pain.

Methods

Participants included 19 youth ages 10-17 years with chronic IBD pain and their parents, and 5 IBD providers from a gastroenterology clinic. Separate semi-structured qualitative interviews with youth, parents, and providers were conducted. Interview prompts were adapted from CAMSA, previous studies of pediatric pain and symptom monitoring, and a qualitative study in adults with IBD pain. Interviews were analyzed according to principles of reflexive thematic analysis.

Results

Three key components of CAMSA (IBD Threat, Fear/Worry, and Biased Attending) were identified in youth and parent dyads. Some youth showed Biased Attending, including difficulty disengaging, while other youth simply monitored pain. The overarching theme for provider interviews was Gastroenterologists view pain as a secondary (rather than primary) treatment issue.

Conclusions

CAMSA is potentially applicable to pain appraisal in youth with IBD and their parents. When health care providers communicate about pain, they should consider how symptom uncertainty may be influenced by threat, fear/worry, and biased attending. Further studies are needed to develop and test psychosocial interventions to reduce fear and threat of pain in youth with IBD in partnership with families and providers.

Effect of percutaneous electrical nerve field stimulation on mechanosensitivity, sleep, and psychological comorbidities in adolescents with functional abdominal pain disorders

BACKGROUND

Percutaneous electrical nerve field stimulation (PENFS) improves symptoms in adolescents with functional abdominal pain disorders (FAPDs). However, little is known about its impact on sleep and psychological functioning. We evaluated the effects of PENFS on resting and evoked pain and nausea, sleep and psychological functioning, and long-term outcomes.

METHODS

Patient ages 11-19 years with FAPD requiring PENFS as standard care were recruited. Evoked pain was elicited by a Water Load Symptom Provocation Task (WL-SPT) before and after four weeks of treatment. Pain, gastrointestinal symptoms, sleep, somatic symptoms, and physical and psychological functioning were assessed. Actigraphy was used to measure daily sleep-wake patterns.

KEY RESULTS

Twenty patients (14.3 ± 2.2 years old) with FAPD were enrolled. Most patients were females (70%) and white (95%). During pain evoked by WL-SPT, visual analog scale (VAS) pain intensity and nausea were lower following PENFS compared with baseline (p = 0.004 and p = 0.02, respectively). After PENFS, resting VAS pain unpleasantness (p = 0.03), abdominal pain (p < 0.0001), pain catastrophizing (p = 0.0004), somatic complaints (0.01), functional disability (p = 0.04), and anxiety (p = 0.02) exhibited significant improvements, and some were sustained long-term. Self-reported sleep improved after PENFS (p's < 0.05) as well as actigraphy-derived sleep onset latency (p = 0.03).

CONCLUSIONS AND INFERENCES

We demonstrated improvements in resting and evoked pain and nausea, sleep, disability, pain catastrophizing, somatic complaints, and anxiety after four weeks of PENFS therapy. Some effects were sustained at 6-12 months post-treatment. This suggests that PENFS is a suitable alternative to pharmacologic therapy.

Importance of sleep quality in functional abdominal pain disorder in pediatric patients

The incidence of sleep problems is increasing in children, and they are thought to contribute to pain in functional abdominal pain disorder (FAPD). In this study, we aimed to evaluate the pattern of sleep disturbance in children with FAPD and identify the associated factors. We retrospectively analyzed patients aged 12-18 years who were diagnosed with FAPD based on the Rome IV criteria. To assess sleep problems, we used the Korean version of the Pittsburgh Sleep Quality Index (PSQI-K). To evaluate factors associated with sleep disturbances, we used the odds ratios (OR) estimated in logistic regression models. Among the 66 patients evaluated, 57.6% (38/66) had a total PSQI-K score > 5, indicating a significant disturbance in sleep, 52.6% (20/38) had irritable bowel syndrome (IBS), and 47.4% (18/38) had functional abdominal pain-not otherwise specified. The mean PSQI-K score was 7.2 ± 6.0, and longer sleep onset latency was noted (26.33 ± 19.44 min) in all patients than healthy controls. Almost all PSQI-K subscales scores were elevated in patients with IBS. In univariate analysis, abdominal pain score > 7 and IBS were associated with poor sleep quality. In multivariate analysis, only IBS was associated with sleep disturbance. A relatively large proportion of patients with FAPD had sleep problems and these were more common in patients with IBS. Thus, interventions for improving sleep quality should also be considered in patients with FAPD with severe abdominal pain and IBS.

Internet-delivered cognitive behavioral therapy for youth with functional abdominal pain: a randomized clinical trial testing differential efficacy by patient subgroup

ABSTRACT

Inconsistent results of psychological treatments for pediatric functional abdominal pain (FAP) may be due to heterogeneity of patients' pain-related psychological characteristics. This randomized controlled trial tested whether statistically derived patient subgroups (high pain dysfunctional [HPD], high pain adaptive [HPA], and low pain adaptive [LPA]) moderated response to cognitive behavior therapy (CBT) for adolescents with FAP and their parents (n = 278 dyads; patients were 66% female, mean [SD] age was 14.62 [1.88] years, and parents were 95% female). Randomization to Internet-delivered CBT vs Internet-delivered pain education (EDU) was stratified by patient subgroup. Follow-up assessments of gastrointestinal (GI) symptoms (primary outcome), abdominal pain, and pain interference were at midtreatment, posttreatment, 6 months, and 12 months. Data were analysed using linear mixed effects models. Significant treatment × subgroup × time interaction effects showed that patient subgroup significantly moderated the effect of treatment on GI symptoms (t[853 = -2.93, P = 0.003) and abdominal pain (t(844) = -2.14, P = 0.03) across the treatment period. Among HPD youth, those in CBT had significantly greater GI symptom reduction than those in EDU through posttreatment. By contrast, among HPA and LPA youth, symptom improvement did not differ by treatment condition. Furthermore, among all patients assigned to CBT, HPD youth demonstrated significantly greater reductions in GI symptoms compared with HPA and LPA youth and greater reductions in abdominal pain compared with LPA youth. All subgroups maintained symptom reductions throughout the follow-up period. Results suggest that subgrouping FAP patients may inform treatment allocation and optimize treatment response.

Does Quantitative Sensory Testing Improve Prediction of Chronic Pain Trajectories? A Longitudinal Study of Youth With Functional Abdominal Pain Participating in a Randomized Controlled Trial of Cognitive Behavioral Treatment

OBJECTIVES

Youth with functional abdominal pain (FAP) experience significant pain-related distress and functional impairment. Although quantitative sensory testing protocols have identified alterations in pain modulatory systems that distinguish youth with FAP from healthy controls, the extent to which evoked pain responses predict subsequent trajectories of pain symptoms and disability over and above established psychosocial risk factors is unclear.

METHODS

The present study included 183 adolescents with FAP who were enrolled in a randomized controlled trial comparing an 8-week, internet-delivered program of cognitive behavior therapy (n=90) or pain education (n=93). Participants completed a quantitative sensory testing protocol before the intervention and were followed for 12-month posttreatment.

RESULTS

Whereas adolescents with FAP who exhibited stronger baseline conditioned pain modulation (CPM) reported decreases in pain-related interference over follow-up (b=-0.858, SE=0.396, P=0.032), those with weaker CPM exhibited high, relatively stable levels of pain-related interference over time (b=-0.642, SE=0.400, P=0.110). CPM status predicted changes in pain-related interference after controlling for the effects of treatment condition and psychosocial risk factors. Static measures of pain sensitivity (ie, pain threshold, pain tolerance) and temporal summation of second pain were not associated with changes in measures of abdominal pain, gastrointestinal symptom severity, or pain-related interference over follow-up.

DISCUSSION

The present findings contribute to a growing literature on the predictive utility of quantitative sensory testing indices and suggest that CPM may complement existing psychosocial risk measures in determining individualized pain-related risk profiles.

Comorbid Sleep Disturbance in Adolescents with Functional Abdominal Pain

OBJECTIVE/BACKGROUND

Sleep disturbances have been commonly reported as comorbid in youth with pain conditions, but prior research specific to functional abdominal pain (FAP) is limited. This study describes individual factors associated with increased risk for sleep disturbance and characterizes the relationship between sleep disturbance and pain-related variables.

PARTICIPANTS

Participants included 278 adolescents (age 11 to 17 years, M age = 15 years; 89% Caucasian; 65% female) with FAP.

METHODS

Participants reported on sleep disturbances, abdominal pain severity, functional disability, somatic symptoms, and healthcare utilization.

RESULTS

Female adolescents reported greater sleep disturbance than male adolescents (t(276) = 5.52, p < .001, Cohen's d = 0.70) and increased age was associated with greater sleep disturbance (r =.20, p =.001). In hierarchical regressions controlling for age, sex, and abdominal pain, greater sleep disturbance was significantly associated with greater functional disability (β =.32), non-gastrointestinal somatic symptoms (β =.35), and emergency department visits (β =.29).

CONCLUSIONS

Results suggest that sleep disturbance is common and should be assessed in youth presenting with FAP and may be a potential target for intervention.

Systematic Review: Psychosocial Correlates of Pain in Pediatric Inflammatory Bowel Disease

BACKGROUND

Pain is a common symptom in pediatric inflammatory bowel disease (IBD) and is associated with poor health outcomes, yet additional knowledge about the psychosocial correlates of pain is needed to optimize clinical care. The purpose of this study is to systematically review the psychosocial factors associated with pain and pain impact in youth diagnosed with IBD within a developmentally informed framework.

METHODS

Manual and electronic searches yielded 2641 references. Two authors conducted screening (98% agreement), and data extraction was performed in duplicate. Average study quality was rated using the National Institutes of Health Quality Assessment Tool.

RESULTS

Ten studies (N = 763 patients; N = 563 Crohn disease, N = 200 ulcerative/ indeterminate colitis) met the inclusion criteria. Findings showed consistent evidence that higher levels of child depression symptoms and child pain catastrophizing were associated with significantly greater pain and pain impact (magnitude of association ranged from small to large across studies). Greater pain and pain impact were also associated with higher levels of child anxiety symptoms, child pain threat, child pain worry, and parent pain catastrophizing. Within the included studies, female sex and disease severity were both significantly associated with pain and pain impact. Study quality was moderate on average.

CONCLUSIONS

There is evidence that child psychosocial factors are associated with pain and pain impact in pediatric IBD; more studies are needed to examine parent- and family-level psychosocial factors. Youth with IBD should be routinely screened for pain severity, pain impact, and psychosocial risk factors such as anxiety/depression.

Determinants of quality of life and psychosocial adjustment to pediatric inflammatory bowel disease: A systematic review focused on Crohn's disease

BACKGROUND

Crohn's disease is a chronic and unpredictable inflammatory bowel disease that leads to important psychosocial difficulties especially during sensitive developmental stages such as childhood and adolescence. While risk factors for mood disorders have been identified in the literature, those for quality of life and psychosocial functioning have not.

OBJECTIVE

This systematic review explored the determinants of quality of life and psychosocial adjustment to pediatric Crohn's disease.

METHOD

Four international databases were consulted in March 2020: PubMed, PsychInfo, PubPsych and Cochrane Library. A series of keywords were entered in each database to identify the most recent relevant studies.

RESULTS

One hundred and sixty-eight articles were identified, of which twenty-nine met the inclusion criteria. The majority explored the determinants of quality of life, depression and anxiety, with a few focusing on psychosocial functioning. Consistently with the literature on psychological morbidity, disease activity and parental stress were also strong predictors of quality of life and psychosocial functioning. New evidence showed that abdominal pain, negative illness perceptions and internalizing symptoms were also common predictors of these outcomes.

CONCLUSIONS

Some risk factors of quality of life, distress and psychosocial functioning are similar, which could indicate that some patients could be at risk of presenting an accumulation of difficulties adjusting to the disease. The identification of these risk factors is fundamental to propose appropriate interventions. Therapeutic education, therapies focused on pain management or on the parent-child relationship can be considered to allow a better adjustment or prevent difficulties.

Clinical Hypnosis in Pediatric Crohn's Disease: A Randomized Controlled Pilot Study

OBJECTIVE

The aim of this study was to implement clinical hypnosis (CH) as an adjunctive therapy for adolescents with Crohn's disease (CD) and to assess the impact of CH on quality of life (QoL), abdominal pain, psychosocial measures, and disease activity compared with standard care.

METHODS

Forty adolescents with CD were randomized to a hypnosis intervention (HI) or waitlist control (WC) group. The intervention consisted of 1 in-person CH session, self-hypnosis education, and recordings for home practice. Data was collected at baseline, after the 8-week intervention, and at week 16. The primary outcome was patient- and parent-reported QoL; secondary outcomes were patient-reported abdominal pain, depression, anxiety, and sleep; school absences; and disease activity by Pediatric Crohn's Disease Activity Index. Paired and independent t-tests were used to compare differences from baseline to postintervention within and between groups.

RESULTS

Forty patients (50% girls, mean 15.8 years) were enrolled from February to May 2019. Seventy-eight percent had inactive disease, and 55% had abdominal pain. Post intervention, significant improvements were noted in HI parent-reported QoL compared with WC in total score (P = 0.05), social functioning (P = 0.01), and school functioning (P = 0.04) but patient-reported QoL was unchanged. Abdominal pain severity significantly improved in HI compared with WC (P = 0.03). School absences decreased in significantly more intervention than control patients (P = 0.01). Patients who practiced self-hypnosis consistently showed a trend toward greater QoL improvement than those who did not (P = 0.1).

CONCLUSIONS

CH is an acceptable and feasible adjunct in CD and may improve psychosocial QoL and abdominal pain. Further research is warranted.

Validation of the Health-Related Felt Stigma and Concealment Questionnaire

OBJECTIVE

Stigma is associated with many health conditions, including chronic pain. Research on health-related stigma is limited by the lack of validated instruments that distinguish among various stigma-related constructs. We aimed to develop and validate such a measure for pediatric functional abdominal pain (FAP). Felt stigma (FS) was defined as comprising both perceived and internalized stigma. Stigma concealment (SC) was defined as efforts by stigmatized individuals to prevent others from learning of their condition.

METHODS

Using a theory-driven approach, we adapted items from existing self-report measures of stigma to construct the health-related FS and Concealment Questionnaire (FSC-Q). Patients with FAP (N = 179, ages 11-17) completed the preliminary FSC-Q and health-related measures hypothesized to be associated with stigma. Cognitive interviewing and exploratory factor analysis (EFA) informed the final version of the measure.

RESULTS

EFA identified a 2-factor model comprised of FS and SC. The FS and SC scales exhibited good internal consistency and construct validity. Consistent with study hypotheses, both factors were significantly associated with anxiety, depression, pain catastrophizing, pain threat, physical symptoms, and pain interference/disability. Higher FS was associated with higher mental healthcare utilization. The subset of participants meeting criteria for irritable bowel syndrome (IBS) reported higher FS and SC compared with those without IBS.

CONCLUSION

The FSC-Q may help advance research on health-related stigma in FAP and other chronic health conditions by allowing for assessment of distinct stigma-related constructs.

Psychometric Properties of the Abdominal Pain Index (API) in the Iranian Adolescent Population

Considering the high prevalence of abdominal pain in children and adolescents in Iran, it is essential to use appropriate screening tools. One of the most comprehensive, yet concise, tools for this purpose is the Abdominal Pain Index (API). This study aimed to investigate the psychometric properties of the Persian version of the self-report API in adolescents. In this descriptive study, A total of 162 Iranian adolescents in the age range of 12 to 18 years were considered as the sample group, which included two groups of school students (n = 125) and adolescent patients with abdominal pain (n = 37). Clinical sample was selected by the available sampling method, and nonclinical sample was selected by the cluster sampling method. Adolescents in the sample group were selected from both clinical and nonclinical groups in order to evaluate differential validity. Instruments, including API, somatic symptoms subscale of the General Health Questionnaire (GHQ), and McGill Pain Questionnaire (MPQ), were also completed for the participants. Also, to evaluate the construct validity of API, exploratory and confirmatory factor analysis methods were applied. The exploratory factor analysis identified one general factor, and the confirmatory factor analysis results show the model's satisfactory fitting. Also, the researchers' hypothesis, i.e., API is a single-factor model (with five items), was approved. The reliability coefficient of the questionnaire was satisfactory for the total scale (α < 0.7). This study showed that API could be used with considerable confidence for Iranian children and adolescents with chronic pain.

Subgroups of Pediatric Patients With Functional Abdominal Pain: Replication, Parental Characteristics, and Health Service Use

OBJECTIVES

Prior work in a cohort of youth with functional abdominal pain (FAP) identified patient subgroups (High Pain Dysfunctional, High Pain Adaptive, Low Pain Adaptive) that predicted differences in the course of FAP from childhood into young adulthood. We aimed to replicate these subgroups in a new sample of adolescents with FAP using the original classification algorithm and to extend subgroup characteristics to include parental characteristics and health service use.

METHODS

Adolescents (n=278; ages 11 to 17 y, 66% females) presenting to a gastroenterology clinic for abdominal pain, and their parents (92% mothers) completed self-report measures; adolescents also completed a 7-day pain diary.

RESULTS

The replicated patient subgroups exhibited distress and impairment similar to subgroups in the original sample. Moreover, in novel findings, the High Pain Dysfunctional subgroup differed from other subgroups by the predominance of mother-daughter dyads jointly characterized by high levels of anxiety, depressive symptoms, pain behavior, and pain catastrophizing. The High Pain Dysfunctional subgroup used more health care services than Low Pain Adaptive but did not differ from High Pain Adaptive.

DISCUSSION

Findings replicate and extend the original FAP classification and suggest that the subgroups have unique patient and parent features that may reflect distinct illness mechanisms requiring different treatments.

Understanding the Experience of Functional Abdominal Pain Through Written Narratives by Families

OBJECTIVE

Although functional abdominal pain (FAP) is one of the most common pain problems in children, there is a lack of qualitative studies on this topic. Our aim was to increase knowledge in this field by testing an innovative written narrative methodology designed to approach the experiences of children with FAP and their parents.

METHODS

We analyzed the FAP experiences of 39 families who completed a written narrative task (children and parents separately). Some of the families (N = 20) had previously completed an online psychosocial intervention, whereas others had not, because a complementary objective was to explore possible differences between parent and child narratives, and between those who had and had not completed the intervention.

RESULTS

Families wrote about abdominal pain (characteristics, triggers, pain consequences, and coping strategies), their well-being, the diagnostic process, future expectations, and the positive effects of an online psychosocial intervention. Children tended to mention pain characteristics more, whereas parents tended to write more about triggers and the diagnostic process.

CONCLUSIONS

A written narrative methodology was found to be a useful approach for understanding families' experiences. Results confirmed that FAP affects families at the emotional, behavioral, and social levels and that an online psychosocial intervention can help families.

Effects and Experiences of Families Following a Web-Based Psychosocial Intervention for Children with Functional Abdominal Pain and Their Parents: A Mixed-Methods Pilot Randomized Controlled Trial

Purpose

To evaluate post-treatment efficacy of DARWeb (online psychosocial intervention for children with functional abdominal pain) using a randomized clinical trial design and combining quantitative and qualitative data.

Patients and methods

Twenty-five families with children with FAP in the experimental group (EG: accessed to DARWeb) and 36 in the control group (CG: wait-list) were compared. Children and parents completed measures of abdominal pain severity (primary outcome), quality of life, and satisfaction. Moreover, children completed measures of depression, functional disability, catastrophizing and coping strategies; parents completed measures about parental responses to their children's pain. Families also answered open questions and were interviewed.

Results

A higher percentage of children in the EG achieved a significant clinical change in abdominal pain severity from the parents' perspective (28% in the EG vs 8.33% in the CG). There was a significantly greater reduction in pain frequency in the EG compared to the CG (both from the children's and parents' perspectives) from mixed repeated-measures analyses of variance (there was not a significant interaction in total scores of pain severity). A higher percentage of children in the EG improved in quality of life and depression compared to the CG (results from mixed methods repeated-measures analyses of variances were not significant). However, there were no differences for disability, pain catastrophizing or the coping strategies assessed from the children's perspective; neither from the parents' assessment of quality of life. There were significant interactions for parents' solicitousness responses and promotion of well behaviors in the expected directions. Families were quite satisfied with the intervention, and the qualitative results confirmed an improvement in pain and having learned important coping strategies.

Conclusion

Our results support the efficacy of our intervention, but future studies are needed with different profiles of initial severity of the pain problem, longer follow-ups, and other conditions.

Web-based cognitive-behavioral intervention for pain in pediatric acute recurrent and chronic pancreatitis: Protocol of a multicenter randomized controlled trial from the study of chronic pancreatitis, diabetes and pancreatic cancer (CPDPC)

INTRODUCTION

Abdominal pain is common and is associated with high disease burden and health care costs in pediatric acute recurrent and chronic pancreatitis (ARP/CP). Despite the strong central component of pain in ARP/CP and the efficacy of psychological therapies for other centralized pain syndromes, no studies have evaluated psychological pain interventions in children with ARP/CP. The current trial seeks to 1) evaluate the efficacy of a psychological pain intervention for pediatric ARP/CP, and 2) examine baseline patient-specific genetic, clinical, and psychosocial characteristics that may predict or moderate treatment response.

METHODS

This single-blinded randomized placebo-controlled multicenter trial aims to enroll 260 youth (ages 10-18) with ARP/CP and their parents from twenty-one INSPPIRE (INternational Study Group of Pediatric Pancreatitis: In search for a cuRE) centers. Participants will be randomly assigned to either a web-based cognitive behavioral pain management intervention (Web-based Management of Adolescent Pain Chronic Pancreatitis; WebMAP; N = 130) or to a web-based pain education program (WebED; N = 130). Assessments will be completed at baseline (T1), immediately after completion of the intervention (T2) and at 6 months post-intervention (T3). The primary study outcome is abdominal pain severity. Secondary outcomes include pain-related disability, pain interference, health-related quality of life, emotional distress, impact of pain, opioid use, and healthcare utilization.

CONCLUSIONS

This is the first clinical trial to evaluate the efficacy of a psychological pain intervention for children with CP for reduction of abdominal pain and improvement of health-related quality of life. Findings will inform delivery of web-based pain management and potentially identify patient-specific biological and psychosocial factors associated with favorable response to therapy. Clinical Trial Registration #: NCT03707431.

Associations between attachment and pain: From infant to adolescent

Pain experience is a negative complex phenomenon influenced by several mechanisms. Attachment processes may affect the way in which individuals experience and signal pain. Hence, in the last two decades, the role of attachment quality has drawn attention in pain research and practice. However, previous reviews on this topic focused on adulthood and/or specific types or pain. We conducted a narrative review examining the association between attachment and different pain conditions from infancy to adolescence. Two independent researchers searched scientific databases for relevant papers. A total of 17 articles were included. Results highlight the following: (a) children and adolescents with chronic idiopathic pain showed low rates of attachment security compared to control groups; (b) pain conditions are consistently associated with elevated rates of at-risk pattern of attachment and information processing; and (c) the presence of unresolved trauma or loss is higher in children and adolescent who experienced pain compared to healthy controls. Despite the significance of these empirical evidences, the impact of caregiving environment and interpersonal context on pain experience in infancy and preschool age is poorly investigated compared to adulthood. Research on pain and attachment needs to be extended since the majority of the studies are limited to specific pain conditions. Future research should investigate the role of anxious attachment on procedural pain and transition from acute to chronic pain, testing new conceptual models. These findings shed light on the importance of relational factors and psychosocial vulnerabilities in pain clinical practice. An attachment-informed approach to pain will help health professionals to offer adequate support during procedures and to increase effectiveness of interventions. A developmental perspective is needed to integrate familial and relational contribution into a multimodal assessment and treatment of pain. Longitudinal studies are recommended.

Multidisciplinary Treatment Reduces Pain and Increases Function in Children With Functional Gastrointestinal Disorders

Functional gastrointestinal disorders (FGIDs) are common in children and adolescents, frequently resulting in extensive testing, school absenteeism, disability, and poor quality of life.^1-3 FGIDs result from a complex interplay between genetic predisposition, biological triggers, and psychosocial triggers, and are best explained by the biopsychosocial model.¹ Although this implies the necessity of multidisciplinary treatment, studies showing the efficacy of such an intervention are lacking. We describe the outcome of children with severe FGIDs treated in a multidisciplinary program.

Multiple psychological factors predict abdominal pain severity in children with irritable bowel syndrome

BACKGROUND

Anxiety and depression are implicated as contributors to abdominal pain in pediatric irritable bowel syndrome (IBS) but is unclear if this pain is associated with other psychological factors. The study objective was to test if the impact of anxiety or depression on IBS symptom severity is mediated by somatization and/or pain catastrophizing.

METHODS

We utilized baseline data from local pediatric IBS clinical studies. Through mediation analysis, we assessed whether somatization or pain catastrophizing mediated (either independently or combined) the separate relationships of anxiety or depression with IBS abdominal pain severity.

KEY RESULTS

We analyzed 261 participants. All psychological factors were positively correlated with one another and IBS abdominal pain severity. The association of anxiety with IBS abdominal pain was mediated by both somatization and pain catastrophizing in individual analyses (each mediated standardized coefficient [β] 0.11, CI 0.05-0.18) and in multiple analysis (mediated standardized β 0.18, CI 0.09-0.27). The association of depression with IBS abdominal pain was also mediated by somatization (mediated standardized β 0.08, CI0.02-0.14) and pain catastrophizing (mediated standardized β 0.06, CI 0.01-0.11) in individual analyses and in multiple analysis (mediated standardized β 0.19, CI 0.04-0.19).

CONCLUSIONS AND INFERENCES

Somatization and pain catastrophizing mediate the relationships between anxiety/depression and IBS abdominal pain severity. These findings suggest that somatization and pain catastrophizing may be better treatment targets than anxiety and depression. Clinicians should assess these psychological factors in pediatric IBS patients and refer for intervention to improve outcomes.

Microstructural White Matter Abnormalities in the Dorsal Cingulum of Adolescents with IBS

Alterations in fractional anisotropy (FA) have been considered to reflect microstructural white matter (WM) changes in disease conditions; however, no study to date has examined WM changes using diffusion tensor imaging (DTI) in adolescents with irritable bowel syndrome (IBS). The objective of the present study was two-fold: (1) to determine whether differences in FA, and other non-FA metrics, were present in adolescents with IBS compared to healthy controls using whole-brain, region of interest (ROI)-restricted tract-based spatial statistics (TBSS) and canonical ROI DTI analyses for the cingulum bundle, and (2) to determine whether these metrics were related to clinical measures of disease duration and pain intensity in the IBS group. A total of 16 adolescents with a Rome III diagnosis of IBS (females = 12; mean age = 16.29, age range: 11.96-18.5 years) and 16 age- and gender-matched healthy controls (females = 12; mean age = 16.24; age range: 11.71-20.32 years) participated in this study. Diffusion-weighted images were acquired using a Siemens 3-T Trio Tim Syngo MRI scanner with a 32-channel head coil. The ROI-restricted TBSS and canonical ROI-based DTI analyses revealed that adolescents with IBS showed decreased FA in the right dorsal cingulum bundle compared to controls. No relationship between FA and disease severity measures was found. Microstructural WM alterations in the right dorsal cingulum bundle in adolescents with IBS may reflect a premorbid brain state or the emergence of a disease-driven process that results from complex changes in pain- and affect-related processing via spinothalamic and corticolimbic pathways.

Quantitative and qualitative testing of DARWeb: An online self-guided intervention for children with functional abdominal pain and their parents

The main objective of this study was to preliminary explore the effects of DARWeb on different outcomes. A Quasi-experimental, one-group, pretest-posttest design was used. Parents and children were asked to complete questionnaires and questions (separately) about quality of life, abdominal pain severity, and satisfaction. Semi-structured interviews with families were also performed. This study focuses on 17 families. Results showed that parent's ratings of children's abdominal pain severity were significantly lower after finishing the intervention and at the 3-month follow-up, and quality of life scores had increased significantly after 3 months. From children's ratings, mean abdominal pain severity scores were significantly lower after the intervention compared to the preintervention assessment. Both parents and children were quite satisfied with the intervention. In qualitative interviews, families suggested that DARWeb helped them to give less importance to pain and to learn coping strategies. In conclusion, this study showed the potential usefulness of DARWeb for children with functional abdominal pain and for their parents.

Development and Validation of a Nausea Severity Scale for Assessment of Nausea in Children with Abdominal Pain-Related Functional Gastrointestinal Disorders

The objective of this study was to develop a pediatric measure of chronic nausea severity, the Nausea Severity Scale (NSS), and evaluate its reliability and validity in youth with abdominal pain-related functional gastrointestinal disorders (AP-FGID). Pediatric patients (aged 11–17 years-old, n = 236) presenting to an outpatient clinic for evaluation of abdominal pain completed the NSS, Children’s Somatization Inventory (CSI), Functional Disability Inventory (FDI), Abdominal Pain Index (API), Patient-Report Outcomes Measurement Information System (PROMIS), Anxiety and Depression Scales and the Pediatric Rome III Questionnaire for FGIDs. The NSS demonstrated good concurrent, discriminant, and construct validity, as well as good internal consistency. One-third (34%) of AP-FGID patients reported experiencing nausea “most” or “every day” in the previous two weeks. The severity of nausea was higher in females than males and correlated significantly with the severity of somatic symptoms, functional disability, anxiety, and depression. The NSS is a valid and reliable measure of nausea in children with AP-FGID.

Adolescents' Observations of Parent Pain Behaviors: Preliminary Measure Validation and Test of Social Learning Theory in Pediatric Chronic Pain

Objective

Evaluate psychometric properties of a measure of adolescents’ observations of parental pain behaviors and use this measure to test hypotheses regarding pain-specific social learning.

Methods

We created a proxy-report of the Patient Reported Outcomes Measurement Information System (PROMIS) Pain Behavior–Short Form (PPB) for adolescents to report on parental pain behaviors, which we labeled the PPB-Proxy. Adolescents (n = 138, mean age = 14.20) with functional abdominal pain completed the PPB-Proxy and a parent completed the PPB. Adolescents and their parents completed measures of pain and disability during the adolescent’s clinic visit for abdominal pain. Adolescents subsequently completed a 7-day pain diary period.

Results

The PPB-Proxy moderately correlated with the PPB, evidencing that adolescents observe and can report on parental pain behaviors. Both the PPB-Proxy and PPB significantly correlated with adolescents’ pain-related disability.

Conclusions

Parental modeling of pain behaviors could represent an important target for assessment and treatment in pediatric chronic pain patients.

Comparison of gut-directed hypnotherapy and unspecific hypnotherapy as self-help format in children and adolescents with functional abdominal pain or irritable bowel syndrome: a randomized pilot study

OBJECTIVE

Psychosocial treatments for chronic abdominal pain in childhood or adolescence are effective, but time consuming and hardly available. In the present study, gut-directed hypnotherapy (GDHT) and unspecific hypnotherapy (UHT) were compared to evaluate the feasibility and efficacy of a hypnotherapeutic self-help intervention.

PARTICIPANTS AND METHODS

Children/adolescents between 6 and 17 years of age with chronic abdominal pain were randomized to GDHT or UHT. The treatment period was 12 weeks each. Measurements were performed before and after treatment. The primary outcome was a pain diary. Analysis was carried out as per protocol.

RESULTS

Of 45 participants included, 13 were lost to follow-up. Thirty-two participants (14 GHDT, 18 UHT) were analyzed. Dropouts had higher pain severity. Completers in both conditions showed good adherence and a similar decrease in days with pain and pain duration. Pain intensity decreased only in the UHT condition. Eleven participants (two GDHT, nine UHT) achieved clinical remission (>80% improvement) and 13 participants (seven GDHT, six UHT) improved significantly (30-80%).

CONCLUSION

Results suggest a high efficacy of standardized home-based hypnotherapy for children/adolescents with abdominal pain. Children/adolescents with high pain severity are at risk of dropping out. The UHT condition showed slight evidence of superiority, but conditions were equivalent on most outcomes. Taken together, self-help approaches based on hypnotherapy could close a treatment gap and prevent chronification.

High Cost and Low Yield: The Diagnostic Evaluation of Rumination Syndrome in Pediatrics

OBJECTIVE

To document the use of diagnostic testing in adolescents who ultimately were diagnosed with rumination syndrome, a functional gastrointestinal disorder. We examined the diagnostic yield of each test as well as the associated costs, and we determined if any demographic or illness-related variables impacted the magnitude of the work-up.

STUDY DESIGN

A retrospective chart review was conducted for 68 patients with rumination syndrome admitted to our inpatient treatment program. The cost and findings of patients' diagnostic investigations were gathered, as well as demographic and illness-related variables to determine factors that may be related to evaluation size.

RESULTS

The most commonly used tests in the evaluation of rumination syndrome included esophagogastroduodenoscopy, gastric emptying, antroduodenal manometry, upper gastrointestinal series, and abdominal ultrasound scan. Each patient underwent an average of 8.8 tests, with the average cost for each patient's diagnostic work-up being US $19 795. Few tests were found to be beneficial in the diagnosis of rumination syndrome, and few demographic or illness variables were found to be related to the overall extent of the investigation.

CONCLUSIONS

Extensive testing for rumination syndrome in adolescents is common in clinical practice, and comes at a high financial cost with low yield, likely delaying diagnosis and treatment. Symptom-based criteria should be used to make the diagnosis of rumination syndrome.

Nausea in Children With Functional Abdominal Pain Predicts Poor Health Outcomes in Young Adulthood

BACKGROUND & AIMS

Nausea is common among children with functional abdominal pain (FAP). We evaluated the relation of nausea to short- and long-term morbidity in pediatric patients with FAP.

METHODS

We performed a prospective study of 871 children with FAP (age, 8-17 y) seen in a pediatric gastroenterology practice; follow-up data were collected from 392 of the patients at 8.7 ± 3.3 years later. Participants were defined as having significant nausea if they reported nausea "a lot" or "a whole lot" within the past 2 weeks. Validated questionnaires assessed abdominal pain, gastrointestinal and somatic symptoms, and depression. Baseline measures, anxiety, and the Rome III criteria were assessed in the follow-up evaluation.

RESULTS

At baseline, 44.8% of the patients reported significant nausea. Those with nausea reported worse abdominal pain, gastrointestinal symptoms, somatic symptoms, and depression than those without nausea (P < .001 for all). When the children had reached young adulthood, those with nausea in childhood continued to have more severe gastrointestinal (P < .001) and somatic symptoms (P = .003) than patients without nausea in childhood, as well as higher levels of anxiety (P = .02) and depression (P = .02). In the follow-up evaluation, somatic symptoms, depression, and anxiety remained significant after controlling for baseline abdominal pain severity.

CONCLUSIONS

Pediatric patients with FAP and nausea have more severe short- and long-term gastrointestinal and somatic symptoms than patients with FAP without nausea, as well as reductions in mental health and daily function. Pediatric patients with FAP and nausea therefore need intensive treatment and follow-up evaluation.

Brief telephone-delivered cognitive behavioral therapy targeted to parents of children with functional abdominal pain: a randomized controlled trial

Pediatric functional abdominal pain disorders (FAPDs) are associated with increased health care utilization, school absences, and poor quality of life (QoL). Cost-effective and accessible interventions are needed. This multisite study tested the effects of a 3-session cognitive behavioral intervention delivered to parents, in-person or remotely, on the primary outcome of pain severity and secondary outcomes (process measures) of parental solicitousness, pain beliefs, catastrophizing, and child-reported coping. Additional outcomes hypothesized a priori and assessed included functional disability, QoL, pain behavior, school absences, health care utilization, and gastrointestinal symptoms. The study was prospective and longitudinal (baseline and 3 and 6 months' follow-up) with 3 randomized conditions: social learning and cognitive behavioral therapy in-person (SLCBT) or by phone (SLCBT-R) and education and support condition by phone (ES-R). Participants were children aged 7 to 12 years with FAPD and their parents (N = 316 dyads). Although no significant treatment effect for pain severity was found, the SLCBT groups showed significantly greater improvements compared with controls on process measures of parental solicitousness, pain beliefs, and catastrophizing, and additional outcomes of parent-reported functional disability, pain behaviors, child health care visits for abdominal pain, and (remote condition only) QoL and missed school days. No effects were found for parent and child-reported gastrointestinal symptoms, or child-reported QoL or coping. These findings suggest that for children with FAPD, a brief phone SLCBT for parents can be similarly effective as in-person SLCBT in changing parent responses and improving outcomes, if not reported pain and symptom report, compared with a control condition.

Pediatric Pain Beliefs Questionnaire: Psychometric Properties of the Short Form

Cognitive appraisals inform and shape individuals' pain experiences. As researchers examine mechanisms of cognitive-behavioral interventions for chronic pain, psychometrically sound measures based in cognitive theory are needed to directly assess pain beliefs. The Pain Beliefs Questionnaire (PBQ), a 32-item self-report measure informed by coping and appraisal theory, was designed to assess children's pain threat appraisals, problem-focused pain coping efficacy, and emotion-focused pain coping efficacy. The present study aimed to: 1) create a short form of the PBQ, and 2) evaluate the psychometric properties of the reduced measure in a large database of pediatric patients with functional abdominal pain (n = 871). Item reduction analyses identified an 18-item short form of the PBQ (PBQ-SF) that exhibited psychometric properties similar to the original measure. All 3 subscales of the PBQ-SF exhibited strong internal consistency (α levels ranged from .79 to .80) and adequate test-retest reliability at 2 weeks. Evidence for construct validity was provided by examining patterns of partial correlations for each subscale. The PBQ-SF represents a valid and reliable measure for evaluating children's pain beliefs. Future studies should investigate the treatment sensitivity of the PBQ-SF to evaluate its appropriateness for use in clinical trials.

PERSPECTIVE

This article presents the psychometric properties of a reduced 18-item version of a measure used to assess children's pain beliefs in a large sample of children with functional abdominal pain. This measure could help identify processes and individual differences underlying children's responses to psychological treatments for chronic pain.

Abdominal Pain, the Adolescent and Altered Brain Structure and Function

Irritable bowel syndrome (IBS) is a functional gastrointestinal (GI) disorder of unknown etiology. Although relatively common in children, how this condition affects brain structure and function in a pediatric population remains unclear. Here, we investigate brain changes in adolescents with IBS and healthy controls. Imaging was performed with a Siemens 3 Tesla Trio Tim MRI scanner equipped with a 32-channel head coil. A high-resolution T1-weighted anatomical scan was acquired followed by a T2-weighted functional scan. We used a surface-based morphometric approach along with a seed-based resting-state functional connectivity (RS-FC) analysis to determine if groups differed in cortical thickness and whether areas showing structural differences also showed abnormal RS-FC patterns. Patients completed the Abdominal Pain Index and the GI Module of the Pediatric Quality of Life Inventory to assess abdominal pain severity and impact of GI symptoms on health-related quality of life (HRQOL). Disease duration and pain intensity were also assessed. Pediatric IBS patients, relative to controls, showed cortical thickening in the posterior cingulate (PCC), whereas cortical thinning in posterior parietal and prefrontal areas were found, including the dorsolateral prefrontal cortex (DLPFC). In patients, abdominal pain severity was related to cortical thickening in the intra-abdominal area of the primary somatosensory cortex (SI), whereas HRQOL was associated with insular cortical thinning. Disease severity measures correlated with cortical thickness in bilateral DLPFC and orbitofrontal cortex. Patients also showed reduced anti-correlations between PCC and DLPFC compared to controls, a finding that may reflect aberrant connectivity between default mode and cognitive control networks. We are the first to demonstrate concomitant structural and functional brain changes associated with abdominal pain severity, HRQOL related to GI-specific symptoms, and disease-specific measures in adolescents with IBS. It is possible such changes will be responsive to therapeutic intervention and may be useful as potential markers of disease progression or reversal.